43-104.09.

Child born out of wedlock; biological mother; affidavit; form.

In all cases of adoption of a minor child born out of wedlock, the biological mother, or an individual acting on behalf of the biological mother and who possesses information provided by the biological mother if the biological mother is unavailable due to death, incapacity, abandonment, or termination of parental rights, shall complete and sign an affidavit in writing and under oath. The affidavit shall be completed and signed before or at the time of execution of the consent or relinquishment and shall be filed with the court prior to the hearing on the petition for adoption. If the biological mother is under the age of nineteen, the biological mother may sign the affidavit despite her minority or the affidavit may be completed and signed by the agency or attorney representing the biological mother based upon information provided by the biological mother. The affidavit shall be in substantially the following form:

AFFIDAVIT OF IDENTIFICATION

I, .................., the mother of a child, state under oath or affirm as follows:

(1) My child was born, or is expected to be born, on the ....... day of ............, ............, at ................., in the State of ................ .

(2) I reside at ................., in the City or Village of ..................., County of .................., State of ................ .

(3) I am of the age of .......... years, and my date of birth is .................... .

(4) I acknowledge that I have been asked to identify the father of my child.

(5) (CHOOSE ONE)

(5A) I know and am identifying the biological father (or possible biological fathers) as follows:

The name of the biological father is ................ .

His last-known home address is ....................... .

His last-known work address is ....................... .

He is .......... years of age, or he is deceased, having died on or about the ............. day of ............, ............, at ........................., in the State of .................... .

He has been adjudicated to be the biological father by the ..................... Court of ................ county, State of .................., case name ..................., docket number ................ .

He ... has ... has not acknowledged paternity in court or in connection with the child's birth certificate.

He ... has ... has not established a familial relationship with the child.

(For other possible biological fathers, please use additional sheets of paper as needed.)

(5B) I am unwilling or unable to identify the biological father (or possible biological fathers). I do not wish or I am unable to name the biological father of the child for the following reasons:

.......... Conception of my child occurred as a result of sexual assault or incest

.......... Providing notice to the biological father of my child would threaten my safety or the safety of my child

.......... Other reason: .............................. .

(6) If the biological mother is unable to name the biological father, the physical description of the biological father (or possible biological fathers) and other information which may assist in identifying him, including the city or county and state where conception occurred:

..................................................

..................................................

..................................................

(use additional sheets of paper as needed).

(7) Under penalty of perjury, the undersigned certifies that the statements set forth in this affidavit are true and correct.

(8) I have read this affidavit and have had the opportunity to review and question it. It was explained to me by ....................... .

I am signing it as my free and voluntary act and understand the contents and the effect of signing it.

Dated this ...... day of ......., ...... .

(Acknowledgment)

...........................

(Signature)